Developing a Discharge Plan

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A discharge plan refers to the process of evaluating and planning for the needs of a patient after the discharge. For the realization of an efficient discharge plan, the process commences with the first encounter in the emergency department followed by an evaluation of each step taken in the course of treatment (Jaganathan, Conway, & Dunlap, 2012). The paper develops an evidence-based plan for health care delivery in response to the instruction questions.

Response to questions 1, 2, 3, and 4

The discharge plan is developed from the perspective of objectives and resources and tools. The objectives of the plan include patient satisfaction, reduction in hospital length of stay, improvement in health quality of a patient, and reduction in unplanned readmission to the hospital (Lin et al., 2012). Various resources and tools are used in this process. The commonly available resources and tools are the Hospital Admission Risk Profile, Probability of Re-Admission, Blaylock Risk Assessment Screen, Family Preference Assessment, and the Patient Participation Preference Assessment (Lin et al., 2012). All these, aid the assessment of physiology, the social environment where the patient will be discharged, and the ability and capacity of the patient’s self-care (Andrietta, Lopes Moreira, & Bottura Leite de Barros, 2011). Table 1 below shows a discharge plan for a patient with heart failure (HF).

A patient admitted with acute heart failure is medically fit for discharge:

Ø When hemodynamic is a stable, developed on evidence-based oral medication and with a stable renal function for a minimum period of one day before the discharge.

Ø Once he or she is educated and advised about self-care

Ø Upon assessment of home or the social environment as well as the capability to self-care

It is appropriate:

Ø To register a patient in programs dealing with disease management

Ø For the general practitioner to see the patient within the first week of discharge

Ø for the hospital cardiology team to see the patient within the first two weeks of discharge

A patient with chronic HF should be followed up with a multidisciplinary heart failure service

Appropriate modality is necessary for delivering the information. Health education is the most appropriate modality (Andrietta, Lopes Moreira, & Bottura Leite de Barros, 2011). Health education will enable delivery in a small amount and at regular interval which is essential for improvement of uptake and retention of information. It can be determined whether a patient understands what to do through involving members of the multidisciplinary in the modality to follow up with the patient at regular interval to confirm they understand the instructions (Jaganathan, Conway, & Dunlap, 2012). Also, the family members will be involved in the program so that they can assist the patient following the plan. Patients are from diverse culture and language backgrounds. Thus, the plan is individualized for adaptability of such challenges (Andrietta, Lopes Moreira, & Bottura Leite de Barros, 2011).

Response to questions 5 and 6

A care plan is supported by professional and legal standards. In the United States, the American Nursing Association (ANA) outlines the standards which provide the framework for nurses (Collins, 2015). The six ANA professional and legal standards applied in the care plan are assessment, diagnosis, outcomes, planning, implementation, and evaluation (Collins, 2015). These standards are applied in writing a care plan. The plan has three components: the problem, goal, and interventions (Collins, 2015). The most recent heart failure guideline is the “2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline.” The guidelines that can be aligned with the professional standards are sections 6 and 7: a series of evaluation of the heart failure patient, and treatment of stage A to stage D, respectively (Yancy et al., 2017). Section 6 can be aligned with assessment, diagnosis, outcomes, and planning of the professional standards because they are all concerned with prevention and diagnosis. Conversely, section 7 can be aligned with implementation and evaluation since all of them are dealing with treatment.

Response to questions 7, 8, and 9

The accountability tools used for measuring the effectiveness of any given care plans are critical pathways or evidence-based practice protocols. Evidence-based practice protocols are tools utilized in helping providers in identification, measurement, and desired patient outcomes among other processes (Huber, 2013). These tools track the system for treatment and intervention, teaching, health outcomes, and complication timing. Critical pathways elaborate care stages and progress expectation (Huber 2013). Measurement of the effectiveness of a plan follows this procedure: on admission, during admission, two days prior discharge, the day of discharge, and follow up care (Waring et al., 2014). The success of a discharge plan is evaluated through patient’s responses and outcomes (Collins, 2015). Thus, positive patient’s responses and outcomes are the ways of knowing that a plan is successful. A successful discharge plan has indicators. Some of the indicators are patient satisfaction, reduction in hospital length of stay, improvement in health quality of a patient, and reduction in unplanned readmission to the hospital (Lin et al., 2012). They are the same indicators for the effectiveness of the plan.

In conclusion

In conclusion, a successful discharge plan and implementation are significant for the patients with heart failures. This is because those with heart failures constitute a high rate of readmissions in the hospitals (Jaganathan, Conway, & Dunlap, 2012). An effective discharge plan is expected to reduce readmissions and improve health quality among other achievements.


Andrietta, M. P., Lopes Moreira, R. S., & Bottura Leite de Barros, A. L. (2011). Hospital discharge plan for patients with congestive heart failure. Revista latino-americana de enfermagem, 19(6), 1445-1452.

Collins, D. (2015). Nursing Care Plans for Home Health Care. Bloomington, IN: LTCS Books.

Huber, D. (2013). Leadership and Nursing Care Management. Amsterdam, Netherlands: Elsevier Health Sciences.

Jaganathan, S. P., Conway, G., & Dunlap, S. (2012). Effective Discharge Planning. In W. F. Peacock (Ed.), Short Stay Management of Acute Heart Failure (pp. 233-242). New York, NY: Humana Press.

Lin, C. J., Cheng, S. J., Shih, S. C., Chu, C. H., & Tjung, J. J. (2012). Discharge planning. International Journal of Gerontology, 6(4), 237-240.

Waring, J., Marshall, F., Bishop, S., Sahota, O., Walker, M. F., Currie, G., ... & Avery, T. J. (2014). An ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: the contributions to ‘safe’hospital discharge. Health Services and Delivery Research, 2(29), 1-160.

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., ... & Hollenberg, S. M. (2017). 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Journal of cardiac failure, 23(8), 628-651.

October 13, 2023

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